Head Injury in Infants, Children and Adults: Triage, Assessment, Investigation and Early Management

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1 Head Injury in Infants, Children and Adults: Triage, Assessment, Investigation and Early Management Information for people who have injured their head, their families and carers NICE Guideline (Patient Version) First Consultation Draft (November 2002) Page 1 of 10

2 The National Institute for Clinical Excellence (NICE for short) is a part of the NHS. It produces guidance for both the NHS and patients on medicines, medical equipment and clinical procedures, and where they should be used. About this information This information describes the guidance that NICE has issued to the NHS on head injuries. It is based on Head injury in infants, children and adults: triage, assessment, investigation and early management; a clinical guideline produced by NICE for doctors, nurses and others working in the NHS in England and Wales. This information has been written for individuals with head injuries, and their parents, family members and carers. Clinical guidelines Clinical guidelines are recommendations for good practice. The recommendations in NICE guidelines are produced by groups of health professionals, lay people (with experience or knowledge of the condition) and scientists. The groups look at the evidence available on the best way of treating or managing a condition and make recommendations based on this evidence. There is more about NICE and the way that NICE guidelines are developed on the NICE website ( You can download the booklet The Guideline Development Process Information for the Public and the NHS from the website, or you can order a copy by phoning What the recommendations cover This booklet covers the recommendations contained in the guidelines Head injury in infants, children and adults: triage, assessment, investigation and early management. These are: managing people before hospital who should go to hospital using skull scanning machines and X-rays who needs surgery sending people home safely information for patients and their carer/s before and during their hospital stay problems after discharge transfers between different departments and hospitals. This guideline covers injuries that might cause damage to the brain or spine; it does not deal with other head injuries (such as eye injuries). It does not cover the long-term care or rehabilitation of people with a head injury, although it does explore possible ways of identifying patients who may need rehabilitation. Page 2 of 10

3 This booklet tells you about the NICE guideline on head injuries. It doesn t attempt to explain head injuries or describe the treatments in detail. If you want to find out more, contact the voluntary organisations listed on page 6. How guidelines are used in the NHS Health professionals working in the NHS are expected to follow NICE s clinical guidelines. But there will be times when the recommendations won t be suitable for someone because of their medical condition, general health, or their wishes. If you think that the treatment or care you, your friend or relative get does not match what is described in this booklet, you should discuss your concerns with your general practitioner (GP). You can get the full and the short version of this guideline from the NICE website ( The full version contains all the details of the guideline recommendations and how they were developed. About head injuries A large number of people injure their heads every year. The most common reasons for head injuries are falls, road traffic accidents and assaults (such as fights). Men and children are most likely to have a head injury. Serious injury to the brain is unusual, because the scalp and skull absorb some of the impact. But complications such as swelling, bruising or bleeding can happen inside the brain. How much damage is done depends on the force and speed of the blow. A head injury can result in clear serious problems, for example you may be in a coma afterwards, or you may have problems that are harder to interpret, such as a headache. If you get help for a head injury, you will be monitored carefully by specially trained and experienced doctors, nurses and paramedics (ambulance staff) who can recognise the important signs and symptoms. Although head injuries are common and can be very serious, very few people die from them. A small number of people who have hurt their head (less than one in a hundred) suffer a serious injury to their brain. About ninety per cent of people seen in hospital have a mild or minor head injury; and most will be able to go home after 48 hours. About concussion Many people who go to the Accident and Emergency (A & E) department of a hospital with a head injury will have been knocked out, or concussed. This means that they lost consciousness for a short time, but afterwards appear to be back to normal. Usually, they cannot recall what happened just before the incident and immediately afterwards. Page 3 of 10

4 A brain scan may fail to show up any problems, but there may be tiny areas of damage that cannot be seen. These can have a major impact on the person s life at home and at work in the weeks, months or years after the injury (see Post-concussion syndrome, below). Many people are unaware that their earlier head injury caused these problems, which are often called unseen injuries. About coma People are said to be in a coma if they are unconscious and unresponsive to the outside world. They may be unable to communicate or obey simple commands, and do not open their eyes, even in response to pain. They may appear to be unaware of sound or touch. Many people who have a head injury are unconscious for a few seconds, hours, days or even a few weeks. There are many levels of consciousness between a deep coma and normal consciousness. People with a head injury can fall anywhere between the two. Doctors use the Glasgow Coma Scale (called GCS) to measure consciousness. The maximum level on this scale is 15 and the lowest is 3. The more severe the injury, the lower the number. (See the Headway leaflet Coma and head injury: how you can help, contact details page 6.) About complications Most complications happen quite quickly after the injury, but problems can show up in the weeks or months later. This is why you will be checked regularly in hospital and followed up after you return home (see Leaving the hospital, page 6). If problems arise it is important to get help and treatment. The main complications are: Intracranial haemorrhage caused by bleeding inside the skull, usually within the first few hours after the injury. The bleeding puts pressure on the brain and is very serious unless treated quickly. Chronic subdural haematoma this happens occasionally when a mixture of blood and fluid builds up on the surface of the brain, several days or weeks after a minor head injury. This pressure on the brain causes headaches, drowsiness, confusion, speech problems or problems down one side of the body. People with any of these symptoms should return to hospital quickly so they can be treated. Post-concussion syndrome this can happen in the weeks or months after being knocked out. Symptoms include headaches, dizziness, poor concentration, memory problems, speaking or listening difficulties, or emotional and behavioural problems such as irritability or short temper. (see Problems after leaving hospital', page 6.) Page 4 of 10

5 What to do if you have a head injury Who should go to Accident and Emergency (A&E)? The symptoms listed below are signs of a very serious head injury. If you get any of them after hurting your head, you should go to your nearest hospital s A&E Department as quickly as possible. Call an ambulance (dial 999) if the injured person has any of the following symptoms and cannot be taken safely to A&E: problems understanding, speaking, reading or writing loss of feeling in part of the body, such as arms or legs problems balancing or walking any changes in eyesight abnormal reflexes any clear fluid running from ears or nose a black eye any skull damage that worries you. If any of the items in the following list apply to the injured person, the chances of having a serious head injury are increased. Take the person to A&E straightaway. (Call an ambulance if you cannot get there safely.) any loss of consciousness (being knocked out ) any problems with memory a headache that won t go away any vomiting or sickness passing out or having a fit previous brain surgery a history of bleeding problems or taking medicine for bleeding problems age 65 or more behaviour changes such as irritability or no interest in things around them, in children under 5 years the person is drunk or has taken drugs a forceful blow to the head at speed (for example, a pedestrian struck by a car, a car or bicycle crash, a diving accident, a fall of 3 feet or more or more than five stairs). Go to A & E if you or your carer have any other serious worries about the injury, or if there is any suspicion it was caused intentionally by the person themselves or someone else. Who should go to their GP? See your GP if you or your carer have any worries about the head injury (not listed above), or if you have nobody to look after you at home. Any child over 5 years old, or any adult whose behaviour has altered since their head injury, should be checked out by a GP. Behaviour changes may include irritability or lack of concentration. Page 5 of 10

6 Your GP may send you to the hospital s A & E Department if they are concerned. This could be by ambulance, car or public transport. What will happen at the hospital? When you arrive in the A&E department, you will be seen first by a triage nurse or doctor who will decide how urgently you need to be dealt with. People who are seriously ill are seen and treated immediately, other people will be seen within 15 minutes of arriving. If you do not need immediate treatment, you may have to wait for a short time to be seen by a doctor. The doctor will examine you to see whether your brain has been affected. This includes checking your level of consciousness and responses. The doctor will ask you about what happened to you. If you can t remember, carers or relatives might be asked to help. What tests will be done on your head? If the doctor thinks you are at risk of developing bleeding inside your skull, a brain scan (computed tomography, or CT scan) will be done. This gives the doctors a picture of the brain inside the skull. Another doctor called a radiologist will do the CT scan. It will usually happen within an hour of your examination. A CT scan is painless. You lie on a couch that slides into the CT machine. Your head goes into the scanner but you can easily see out. It takes between 3 and 20 minutes. A baby or child, or someone who is very agitated, may be given sedatives or even an anaesthetic so that they keep still when they are inside the scanner. You may be given a head X-ray rather than a CT scan. This might be because the hospital doesn t have enough CT scanning machines, or it might be for other reasons. If this happens, you or your carer should ask the doctor why you are getting an X-ray rather than a CT scan. A few people are given an extra test called magnetic resonance imaging (MRI). This is similar to a CT scan, except that the whole body goes into the machine. It gives a very detailed picture of the brain. If the doctors are worried about a possible injury to your spine in the neck region (called the cervical spine) they will ask for a neck X-ray. A CT scan of the neck may be done because the X-ray machine cannot cover all the areas the doctor wants to look at. Are these tests safe? X-rays and CT scans use radiation to get the pictures the doctors want. CT scans give a much more detailed picture than X-rays, so they need to use more radiation. The radiation from a CT scan is between 30 and 40 times higher than an X-ray. Page 6 of 10

7 The difference for babies and children is even greater, so doctors will be very careful. They should use these tests only if absolutely necessary. The risks of developing a disease like cancer after a CT scan are tiny. In an average year, people absorb slightly more radiation from their natural environment (such as water, earth and air) than they would from one CT scan. Having too many X-rays and CT scans can increase the risks of diseases like cancer, so they are used with care. Who gets admitted to hospital? If the tests come back normal, you will usually be sent home. But some people with normal results are kept in hospital for observation. This may be because the doctors are concerned about them, they may be drunk or have taken drugs, they may have other injuries or health problems, or they may be in shock. If the tests show a possible problem, you will be admitted to hospital. Many people have bruises on their brain that do not lead to serious bleeding, but need to be monitored. Regular checks are made, including shining lights into their eyes, and checking their reflexes. Action must be taken quickly if complications develop, so they may need to be woken and checked throughout the night. Many people will be allowed home after a few days. Others become ill while they are in hospital. If this happens, the A&E doctor will talk to a neurosurgeon and decide what treatment is needed. If there is serious bleeding inside your skull, or if the neurosurgeon feels that you should be under his or her care, you may be transferred to a neurosurgical unit for treatment. This may be within the same hospital or it may be in another hospital, possibly some distance away. Transfer to another hospital Moving someone with a head injury to another hospital could be a dangerous procedure. Normally you will go by ambulance, but it may be by helicopter. An experienced anaesthetist or other doctor will usually go with you to make it as safe as possible. You may be given an anaesthetic before the journey if there is a chance of breathing problems or if you are agitated. Families and carers should be fully informed about why you need to be transferred, and about how this will happen. It may be possible for a carer to travel in the ambulance if the injured person is a baby or a young child, but passengers are not normally allowed. Page 7 of 10

8 Operations on the brain Surgery is only performed in the most serious situations. Any bleeding inside the skull must be stopped and any blood clots removed before the brain gets damaged. There may not be time to fully discuss the surgery beforehand, but the neurosurgeon will explain what has happened afterwards. Leaving the hospital You will be able to go home when the doctors think it is safe. You will get a discharge letter advising you how to behave in the first few weeks at home (see Dos and don ts below). You or your carer may be given a letter from the hospital for your GP, who needs to know about your head injury. You may be asked to make an appointment with your GP. The GP will get the results of any tests from the hospital, but this may take some time. If the injured person is a baby or a school age child, their test results will also be sent to their community paediatrician or to their school medical officer. Dos and Don ts DO NOT stay at home alone for the first 48 hours after leaving hospital. DO make sure you stay within easy reach of a telephone and medical help. DO have plenty of rest and avoid stressful situations. DO NOT take any alcohol or drugs. DO NOT take sleeping pills, sedatives or tranquillisers unless they are given by a doctor. DO NOT play any contact sport (such as rugby or football) for at least 3 weeks without talking to your doctor first. DO NOT drive a car, motorbike or bicycle, operate machinery or return to work unless you feel you have completely recovered (if in doubt, talk to your GP). DO contact the voluntary organisations listed on page 6 for ongoing support, information and help for head injured people, their carers and families. If you have problems after leaving hospital You are unlikely to have any further problems when you return home. But if you get any of the symptoms listed on page 5 ('Who should go to A&E ) or if any of your old symptoms return, you should go straight to your nearest hospital s A & E Department. Other reasons for going to A&E are feeling confused (not knowing where you are, getting things muddled up) or feeling sleepy for longer than 1 hour (at a time when you would normally be wide awake). Carers should take the injured person to hospital if they are difficult to wake up. Page 8 of 10

9 Some people have problems in the first few days, which disappear within a week or two. These are not usually anything to worry about and include a mild headache, or feeling sick (without vomiting) tired or dizzy. You may be irritable or bad tempered, or have problems remembering or concentrating on things. You may lose your appetite or have trouble sleeping. If these problems do not go away after 2 weeks or if you are worried about any of them, go and see your GP. Post-concussion syndrome (see page 5) can cause problems for months or even much longer after the injury, even if your injury was a mild one. You may be given a follow up appointment to see a clinical psychologist or a neurologist 2 months after leaving hospital to discuss and help with these difficulties. If you have not been given an appointment, are having problems, or are worried, ask your GP to arrange one for you. Long-term problems Most people recover quickly from their accident and suffer no long-term problems. A few people will have ongoing problems, and life can be very difficult for them and their families. Some people develop problems immediately, others after a few weeks or months There can be changes to a person s personality and behaviour that are hard to deal with. Sometimes it is not until you have returned to school or work that you feel different or that that things are not the same. You may have memory problems, and forget names, appointments, or where you have put things. You may become easily distracted and have difficulty concentrating, planning and organising. You may feel you cannot achieve anything, and become depressed. It is important to contact your GP as soon as possible if you are having difficulties like this. Voluntary organisations can also help: those listed below offer information, help and support to people who have had a head injury: Headway, North Sherwood Street, Nottingham, NG1 4EE. Tel: (information department). Website: Child Brain Injury Trust, The Radcliffe Infirmary, Woodstock Road, Oxford, OX2 6HE. Tel: Website: British Brain and Spine Foundation, 7 Winchester House, Kennington Park, London SW9 6EJ. Tel: (helpline) Page 9 of 10

10 Some technical terms explained Anaesthetist A doctor who specialises in giving anaesthetics. Brain contusions Bruises on the brain that can be seen on a CT scan. CT (computed tomography) scan A computer-aided X-ray used to provide clear pictures of the brain. Convulsion A fit or a seizure. Epilepsy When a person continues to have fits or seizures (or has more than one). Haematoma A blood clot. Haemorrhage Bleeding. Intracranial pressure (ICP) Pressure inside the skull due to brain swelling or bleeding. Neurosurgeon A brain surgeon. Neurosurgery Operations on the brain. Triage A system to prioritise patients according to the seriousness of their injuries. Ventilator A machine designed to move air in and out of a person s lungs mechanically (life support system). Page 10 of 10

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